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Conducting a Critical Interpretive Synthesis of the Literature on Access to

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Article in BMC Medical Research Methodology · February 2006

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BMC Medical Research
Methodology BioMed Central

Technical advance Open Access

Conducting a critical interpretive synthesis of the literature on
access to healthcare by vulnerable groups
Mary Dixon-Woods*1, Debbie Cavers2, Shona Agarwal3, Ellen Annandale4,
Antony Arthur5, Janet Harvey6, Ron Hsu1, Savita Katbamna7, Richard Olsen7,
Lucy Smith1, Richard Riley1 and Alex J Sutton1

Address: 1Department of Health Sciences, University of Leicester, 22–28 Princess Road West, Leicester LE1 6TP, UK, 2Division of Oncology/General
Practice, University of Edinburgh, Edinburgh Centre for Neuro-Oncology, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU,
UK, 3Department of Health Sciences, University of Leicester, Leicester General Hospital, Leicester LE5 4PW, UK, 4Department of Sociology,
University of Leicester, Leicester LE1 7RH, UK, 5School of Nursing, University of Nottingham, Queens Medical Centre, Nottingham NG7 2HA, UK,
6Centre for Research in Social Policy, Loughborough University, Leicestershire LE11 3TU, UK and 7Nuffield Research Unit, Department of Health

Sciences, University of Leicester, 22–28 Princess Road West, Leicester LE1 6TP, UK
Email: Mary Dixon-Woods* - md11@le.ac.uk; Debbie Cavers - debbie.cavers@ed.ac.uk; Shona Agarwal - sa144@le.ac.uk;
Ellen Annandale - eca7@le.ac.uk; Antony Arthur - tony.arthur@nottingham.ac.uk; Janet Harvey - J.Harvey@lboro.ac.uk;
Ron Hsu - rth4@le.ac.uk; Savita Katbamna - sk41@le.ac.uk; Richard Olsen - rao1@le.ac.uk; Lucy Smith - lks1@le.ac.uk;
Richard Riley - rdr3@le.ac.uk; Alex J Sutton - ajs22@le.ac.uk
* Corresponding author

Published: 26 July 2006 Received: 19 April 2006

Accepted: 26 July 2006
BMC Medical Research Methodology 2006, 6:35 doi:10.1186/1471-2288-6-35
This article is available from: http://www.biomedcentral.com/1471-2288/6/35
© 2006 Dixon-Woods et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: Conventional systematic review techniques have limitations when the aim of a review is to construct a
critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an
interpretive review of the literature on access to healthcare by vulnerable groups in the UK
Methods: This project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This
approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances
in methods for interpretive synthesis.
Results: Many analyses of equity of access have rested on measures of utilisation of health services, but these are
problematic both methodologically and conceptually. A more useful means of understanding access is offered by the
synthetic construct of candidacy. Candidacy describes how people's eligibility for healthcare is determined between
themselves and health services. It is a continually negotiated property of individuals, subject to multiple influences arising
both from people and their social contexts and from macro-level influences on allocation of resources and configuration
of services. Health services are continually constituting and seeking to define the appropriate objects of medical attention
and intervention, while at the same time people are engaged in constituting and defining what they understand to be the
appropriate objects of medical attention and intervention. Access represents a dynamic interplay between these
simultaneous, iterative and mutually reinforcing processes. By attending to how vulnerabilities arise in relation to
candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for
policy, practice and future research.
Discussion: By innovating with existing methods for interpretive synthesis, it was possible to produce not only new
methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation
of access to healthcare. This theoretical account of access is distinct from models already extant in the literature, and is
the result of combining diverse constructs and evidence into a coherent whole. Both the method and the model should
be evaluated in other contexts.

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Background
Like many areas of healthcare practice and policy, the lit-
erature on access to healthcare is large, diverse, and com-
plex. It includes empirical work using both qualitative and
quantitative methods; editorial comment and theoretical
work; case studies; evaluative, epidemiological, trial,
descriptive, sociological, psychological, management, and
economics papers, as well as policy documents and polit-
ical statements. "Access" itself has not been consistently
defined or operationalised across the field. There are sub-
stantial adjunct literatures, including those on quality in
healthcare, priority-setting, and patient satisfaction. A
review of the area would be of most benefit if it were to
produce a "mid-range" theoretical account of the evidence
and existing theory that is neither so abstract that it lacks
empirical applicability nor so specific that its explanatory
scope is limited.
In this paper, we suggest that conventional systematic
review methodology is ill-suited to the challenges that
conducting such a review would pose, and describe the
development of a new form of review which we term
"Critical Interpretive Synthesis" (CIS). This approach
draws is sensitised to the range of issues involved in con-
ducting reviews that conventional systematic review
methodology has identified, but draws on a distinctive
tradition of qualitative inquiry, including recent interpre-
tive approaches to review [1]. We suggest that that using
CIS to synthesise a diverse body of evidence enables the
generation of theory with strong explanatory power. We
illustrate this briefly using an example based on synthesis
of the literature on access to healthcare in the UK by socio-
economically disadvantaged people.
Aggregative and interpretive reviews
Conventional systematic review developed as a specific
methodology for searching for, appraising, and synthesis-
ing findings of primary studies [2]. It offers a way of sys-
tematising, rationalising, and making more explicit the
processes of review, and has demonstrated considerable
benefits in synthesising certain forms of evidence where
the aim is to test theories, perhaps especially about "what
works". It is more limited when the aim, as here, is to
include many different forms of evidence with the aim of
generating theory [3]. Conventional systematic review
methods are thus better suited to the production of aggre-
gative rather than interpretive syntheses.
This distinction between aggregative and interpretive syn-
theses, noted by Noblit and Hare in their ground-breaking
book on meta-ethnography[1] allows a useful (though
necessarily crude) categorisation of two principal
approaches to conducting reviews [4]. Aggregative reviews
are concerned with assembling and pooling data, may use
techniques such as meta-analysis, and require a basic
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comparability between phenomena so that the data can
be aggregated for analysis. Their defining characteristics are
a focus on summarising data, and an assumption that the
concepts (or variables) under which those data are to be
summarised are largely secure and well specified. Key con-
cepts are defined at an early stage in the review and form
the categories under which the data from empirical stud-
ies are to be summarised.
Interpretive reviews, by contrast, see the essential tasks of
synthesis as involving both induction and interpretation.
Their primary concern is with the development of con-
cepts and theories that integrate those concepts. An inter-
pretive review will therefore avoid specifying concepts in
advance of the synthesis. The interpretive analysis that
yields the synthesis is conceptual in process and output.
The product of the synthesis is not aggregations of data,
but theory grounded in the studies included in the review.
Although there is a tendency at present to conduct inter-
pretive synthesis only of qualitative studies, it should in
principle be possible and indeed desirable to conduct
interpretive syntheses of all forms of evidence, since the-
ory-building need not be based only on one form of evi-
dence. Indeed, Glaser and Strauss [5] in their seminal text,
included an (often forgotten) chapter on the use of quan-
titative data for theory-building.
Recent years have seen the emergence of a range of meth-
ods that draw on a more interpretive tradition, but these
also have limitations when attempting a synthesis of a
large and complex body of evidence. In general, the use to
date of interpretive approaches to synthesis has been con-
fined to the synthesis of qualitative research only [6-8].
Meta-ethnography, an approach in which there has been
recent significant activity and innovation, has similarly
been used solely to synthesise qualitative studies, and has
typically been used only with small samples [9-11]. Few
approaches have attempted to apply an interpretive
approach to the whole corpus of evidence (regardless of
study type) included in a review, and few have treated the
literature they examine as itself an object of scrutiny, for
example by questioning the ways in which the literature
constructs its problematics, the nature of the assumptions
on the literature draw, or what has influenced proposed
solutions.
In this paper we offer a reflexive account of our attempt to
conduct an interpretive synthesis of all types of evidence
relevant to access to National Health Service (NHS)
healthcare in the UK by potentially vulnerable groups.
These groups had been defined at the outset by the
funders of the project (the UK Department of Health Serv-
ice Delivery and Organisation R&D Programme) as chil-
dren, older people, members of minority ethnicities,
men/women, and socio-economically disadvantaged peo-
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ple. We explain in particular our development of Critical
Interpretive Synthesis as a method for conducting this
review.
Methods
Formulating the review question
Conventional systematic review methodology [12,13]
emphasises the need for review questions to be precisely
formulated. A tightly focused research question allows the
parameters of the review to be identified and the study
selection criteria to be defined in advance, and in turn
limits the amount of evidence required to address the
review question.
This strategy is successful where the phenomenon of inter-
est, the populations, interventions, and outcomes are all
well specified – i.e. if the aim of the review is aggregative.
For our project, it was neither possible nor desirable to
specify in advance the precise review question, a priori def-
initions, or categories under which the data could be sum-
marised, since one of its aims was to allow the definition
of the phenomenon of access to emerge from our analysis
of the literature [14]. This is not to say that we did not
have a review question, only that it was not a specific
hypothesis. Instead it was, as Greenhalgh and colleagues
[15] describe, tentative, fuzzy and contested at the outset
of the project. It did include a focus on equity and on how
access, particularly for potentially vulnerable groups, can
best be understood in the NHS, a health care system that
is, unlike most in the world, free at the point of use.
The approach we used to further specify the review ques-
tion was highly iterative, modifying the question in
response to search results and findings from retrieved
items. It treated, as Eakin and Mykhalovskiy [16] suggest,
the question as a compass rather than an anchor, and as
something that would not finally be settled until the end
of the review. In the process of refining the question, we
benefited from the multidisciplinary nature of our review
team: this allowed a range of perspectives to be incorpo-
rated into the process, something that was also helpful
and important in other elements of the review.
Searching the literature
A defining characteristic of conventional systematic
review methodology is its use of explicit searching strate-
gies, and its requirement that reviewers be able to give a
clear account of how they searched for relevant evidence,
such that the search methods can be reproduced. [2]
Searching normally involves a range of strategies, but
relies heavily on electronic bibliographic databases.
We piloted the use of a highly structured search strategy
using protocol-driven searches across a range of electronic
databases but, like Greenhalgh and Peacock [17] found
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that was this unsatisfactory. In particular, it risked missing
relevant materials by failing to pick up papers that, while
not ostensibly about "access", were nonetheless impor-
tant to the aim of the review. We then developed a more
organic process that fitted better with the emergent and
exploratory nature of the review questions. This combined
a number of strategies, including searching of electronic
databases; searching websites; reference chaining; and
contacts with experts. Crucially, we also used expertise
within the team to identify relevant literature from adja-
cent fields not immediately or obviously relevant to the
question of "access".
However, searching generated thousands of potentially
relevant items – at one stage over 100,000 records. A liter-
ature of this size would clearly be unmanageable, and well
exceed the capacity of the review team. We therefore rede-
fined the aim of the searching phase. Rather than aiming
for comprehensive identification and inclusion of all rele-
vant literature, as would be required under conventional
systematic review methodology, we saw the purpose of
the searching phase as identifying potentially relevant
papers to provide a sampling frame. Our sampling frame
eventually totalled approximately 1,200 records.
Sampling
Conventional systematic review methodology limits the
number of papers to be included in a review by having
tightly specified inclusion criteria for papers. Effectively,
this strategy constructs the field to be known as having
specific boundaries, defined as research that has specifi-
cally addressed the review question, used particular study
designs and fulfilled the procedural requirements for the
proper execution of these. Interpretive reviews might con-
struct the field to be known rather differently, seeing the
boundaries as more diffuse and ill-defined, as potentially
overlapping with other fields, and as shifting as the review
progresses. Nonetheless, there is a need to limit the
number of papers to be included in an interpretive synthe-
sis not least for practical reasons, including the time avail-
able. Sampling is also warranted theoretically, in that the
focus in interpretive synthesis is on the development of
concepts and theory rather than on exhaustive summary
of all data. A number of authors [18-20] suggest drawing
on the sampling techniques of primary qualitative
research, including principles of theoretical sampling and
theoretical saturation, when conducting a synthesis of
qualitative literature.
For purposes of our synthesis, we used purposive sam-
pling initially to select papers that were clearly concerned
with aspects of access to healthcare, partly informed by an
earlier scoping study [21] and later used theoretical sam-
pling to add, test and elaborate the emerging analysis.
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Sampling therefore involved a constant dialectic process
conducted concurrently with theory generation.
Determination of quality
Conventional systematic review methodology uses assess-
ment of study quality in a number of ways. First, as indi-
cated above, studies included in a review may be limited
to particular study designs, often using a "hierarchy of evi-
dence" approach that sees some designs (e.g. randomized
controlled trials) as being more robust than others (e.g.
case-control studies). Second, it is usual to devise broad
inclusion criteria – for example adequate randomisation
for RCTs – and to exclude studies that fail to meet these.
Third, an appraisal of included studies, perhaps using a
structured quality checklist, may be undertaken to allow
sensitivity analyses aimed at assessing the effects of
weaker papers.
Using this approach when confronted with a complex lit-
erature, including qualitative research, poses several chal-
lenges. No hierarchy of study designs exists for qualitative
research. How or whether to appraise papers for inclusion
in an interpretive reviews has received a great deal of
attention, but there is little sign of an emergent consensus
[22]. Some argue that formal appraisals of quality may
not be necessary, and some argue that there is a risk of dis-
counting important studies for the sake of "surface mis-
takes" [23]. Others propose that weak papers should be
excluded from the review altogether, and several pub-
lished syntheses of qualitative research have indeed used
quality criteria to make decisions about excluding papers.
[10,24]
We aimed to prioritise papers that appeared to be rele-
vant, rather than particular study types or papers that met
particular methodological standards. We might therefore
be said to be prioritising "signal" (likely relevance) over
"noise" (the inverse of methodological quality) [25]. We
felt it important, for purposes of an interpretive review,
that a low threshold be applied to maximise the inclusion
and contribution of a wide variety of papers at the level of
concepts. We therefore took a two-pronged approach to
quality. First, we decided that only papers that were
deemed to be fatally flawed would be excluded. Second,
once in the review, the synthesis itself crucially involved
judgements and interpretations of credibility and contri-
bution, as we discuss later.
Table 1: Appraisal prompts for informing judgements about quality of papers
Are the aims and objectives of the research clearly stated?
Is the research design clearly specified and appropriate for the aims and objectives of the research?
Do the researchers provide a clear account of the process by which their findings we reproduced?
Do the researchers display enough data to support their interpretations and conclusions?
Is the method of analysis appropriate and adequately explicated?
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To identify fatally flawed papers, we used the criteria in
Table 1, adapted from those proposed (at the time of our
review) by the National Health Service (NHS) National
Electronic Library for Health for the evaluation of qualita-
tive research, to inform judgements on the quality of the
papers. These criteria were used for assessing all empirical
papers (but not those classified as 'reviews') regardless of
study type. The final judgement about inclusion of the
review rested both on an assessment of relevance as well
as on the assessment of the quality of the individual
papers. Decisions about relevance and quality were
recorded, and a small sample of decisions about relevance
and quality was reviewed. In the event, very few papers –
approximately 20 – were excluded on grounds of being
"fatally flawed", because even weak papers were often
judged to have potentially high relevance. The value of
deferring judgements of credibility and contribution until
the synthesis became increasingly evident.
Most fundamentally, as the review progressed, we became
increasingly convinced that the assumption that all stud-
ies deemed to have satisfactorily fulfilled criteria of execu-
tion and reporting can contribute equally to a synthesis is
flawed. As we discuss further below, one of the distinctive
characteristics of a critical interpretive synthesis is its
emphasis not only on summary of data reported in the lit-
erature but also on a more fundamental critique, which
may involve questioning taken-for-granted assumptions.
Data extraction
A data-extraction pro-forma was initially devised to assist
in systematically identifying characteristics of research
participants, methods of data collection, methods of data
analysis and major findings of each paper. For both qual-
itative and quantitative papers, this involved extracting
the titles of the categories and sub-categories using the
terms used in the paper itself and a summary of the rele-
vant material. Practically, however, it proved impossible
to conduct this form of data extraction on all documents
included in the review, including very large documents.
We therefore summarised some documents more infor-
mally, for example using highlighter pen. More generally,
the value of formal data extraction for purposes of this
type of study will require further evaluation.
Conducting an interpretive synthesis
We had intended, at the outset of this project, to use meta-
ethnography, a method for interpretive synthesis where
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there is currently an active programme of methodological
research, [9-11] as our approach to synthesis. However,
this had previously only been used to synthesise qualita-
tive studies. Our experiences of working with a large sam-
ple of papers using multiple methods led us to refine and
respecify some of the concepts and techniques of meta-
ethnography in order to enable synthesis of a very large
and methodologically diverse literature. Eventually we
had made so many amendments and additions to the
original methodology that we felt it was more appropri-
ate, helpful and informative to deem it a new methodol-
ogy with its own title and processes. It is this approach
which we term critical interpretive synthesis (CIS). It is
important to emphasise, however, that CIS is an approach
to review and is not solely a method for synthesis.
Meta-ethnography, as originally proposed [1], involves
three major strategies.:
1. Reciprocal translational analysis (RTA). The key met-
aphors, themes, or concepts in each study report are iden-
tified. An attempt is then made to translate the concepts
into each other. Judgements about the ability of the con-
cept of one study to capture concepts from others are
based on attributes of the themes themselves, and the
concept that is "most adequate" is chosen.
2. Refutational synthesis. Contradictions between the
study reports are characterised, and an attempt made to
explain them.
3. Lines-of-argument synthesis (LOA) involves building
a general interpretation grounded in the findings of the
separate studies. The themes or categories that are most
powerful in representing the entire dataset are identified
by constant comparisons between individual accounts.
Reciprocal translational analysis
Reciprocal translational analysis involves translating find-
ings of one paper into another by systematically compar-
ing findings from each study, using techniques such as
maps. [9] We encountered considerable methodological
and practical problems in trying to apply RTA across a
large set of papers, in part because of the kinds of itera-
tions we were conducting in refining the sample. These
meant that there were difficulties in identifying a stable
"set" of papers on which an RTA could be conducted. RTA
appears to be most suitable for a well-defined, relatively
small (fewer than 50) and complete set of papers, because
substitution or deletion of papers causes problems with
both identifying index concepts and showing which con-
cepts from other papers translate into these. A further
problem is that, when confronted with a very large and
diverse literature such as ours, RTA tends to provide only
a summary in terms that have already been used in the lit-
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erature. Although this may be a useful strategy as a stage
on the way to a more interpretive synthesis, its value may
be more limited than is the case for smaller samples of
qualitative study reports where its benefits have been
more evident.
Before our review, RTA had previously only been used for
synthesising interpretive research, not a large and diverse
body of literature, so this may be one reason why it was
unsuccessful for our purposes. It is important to distin-
guish between the doubtful value of RTA in our synthesis
(particularly because of the size and diversity of the litera-
ture), and the doubtful use of RTA in general. The diversity
of the literature would also have prevented us from under-
taking an aggregative synthesis using meta-analysis, but
this clearly could not be read as a criticism of meta-analy-
sis itself, but of its limitations when applying it to a
diverse literature.
Lines of argument synthesis
Recent work [9-11] has innovated in the methodology of
lines-of-argument (LOA) synthesis originally proposed by
Noblit and Hare by building on Schutz's [26] notions of
"orders" of constructs Schutz used the idea of "first order
construct" to refer to the everyday understandings of ordi-
nary people and "second order construct" to refer to the
constructs of the social sciences. The explanations and
theories used by authors in primary study reports could
therefore be seen as second order interpretations. This
recent work uses LOA synthesis to develop what are
referred to as "third order" interpretations, which build on
the explanations and interpretations of the constituent
studies, and are simultaneously consistent with the origi-
nal results while extending beyond them. Our experiences
have led us to respecify some of this approach.
We suggest that the appropriate way of conceptualising
the output of an LOA synthesis is as a synthesising argu-
ment. This argument integrates evidence from across the
studies in the review into a coherent theoretical frame-
work comprising a network of constructs and the relation-
ships between them. Its function is to provide more
insightful, formalised, and generalisable ways of under-
standing a phenomenon. A synthesising argument can be
generated through detailed analysis of the evidence
included in a review, analogous to the analysis under-
taken in primary qualitative research. It may require the
generation of what we call synthetic constructs, which are
the result of a transformation of the underlying evidence
into a new conceptual form. Synthetic constructs are
grounded in the evidence, but result from an interpreta-
tion of the whole of that evidence, and allow the possibil-
ity of several disparate aspects of a phenomenon being
unified in a more useful and explanatory way.
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What we have called a "synthetic construct" might also be
seen as a "third order construct". We suggest that the term
"synthetic construct" is a more useful term because it is
more explicit, and also because we emphasise that a syn-
thesising argument need not consist solely of synthetic con-
structs. Instead, synthesising arguments may explicitly
link not only synthetic constructs, but also second order
constructs already reported in the literature. In effect,
therefore, our approach does not make this precise dis-
tinction between second and third order constructs.
Refutational syntheses
We further suggest that what Noblit and Hare [1] call "ref-
utational syntheses" are best conducted as part of the
analysis that produces the synthesising argument Few
published meta-ethnographies have in fact reported a sep-
arate refutational synthesis. It is, we suggest, more produc-
tive instead to adopt a critical and reflexive approach to
the literature, including consideration of contradictions
and flaws in evidence and theory.
An important element of producing a synthesising argu-
ment is the need, when conducting the analysis, to con-
sider and reflect on the credibility of the evidence, to make
critical judgements about how it contributes to the devel-
opment of the synthesising argument, and to root the syn-
thesising argument appropriately in critique of existing
evidence. Clearly, credibility depends on the quality of the
research, its currency, and the robustness of its theoretical
base. But more generally, a critical interpretive synthesis is
critical in the broader sense of critique rather than this
more limited sense of critical appraisal, in which each
study is judged against the standards of its type. Critique
may involve identification of the research traditions or
meta-narratives that have guided particular fields of
research [27] as well as critical analysis of particular forms
of discourses. Its aim is therefore to treat the literature as
warranting critical scrutiny in its own right.
Conducting the analysis
Our analysis of the evidence, in order to produce a synthe-
sising argument, was similar to that undertaken in pri-
mary qualitative research. We began with detailed
inspection of the papers, gradually identifying recurring
themes and developing a critique. We then generated
themes that helped to explain the phenomena being
described in the literature, constantly comparing the the-
oretical structures we were developing against the data in
the papers, and attempting to specify the categories of our
analysis and the relationships between them. To facilitate
the process of identifying patterns, themes, and categories
across the large volumes of text-based data in our study,
we used QSR N5 software. However, it is important to
note that, as with any qualitative analysis, full transpar-
ency is not possible because of the creative, interpretive
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processes involved. Nonetheless, the large multidiscipli-
nary team involved in the review, and the continual dia-
logue made necessary by this, helped to introduce "checks
and balances" that guarded against framing of the analysis
according to a single perspective.
A key feature of this process that distinguishes it from
some other current approaches to interpretive synthesis
(and indeed of much primary qualitative research) was its
aim of being critical: its questioning of the ways in which
the literature had constructed the problematics of access,
the nature of the assumptions on which it drew, and what
has influenced its choice of proposed solutions. Our cri-
tique of the literature was thus dynamic, recursive and
reflexive, and, rather than being a stage in which individ-
ual papers are excluded or weighted, it formed a key part
of the synthesis, informing the sampling and selection of
material and playing a key role in theory generation.
Findings: access to healthcare by socio-economically
disadvantaged people
Our critical interpretive synthesis of the literature on
access to healthcare by socio-economically disadvantaged
people in the UK included 119 papers. Early analytic cat-
egories were tentative and contingent, but gradually
became firmed up and more highly specified as our anal-
ysis continued. Our synthesis involved a critique of the
tendency to use measures of utilisation as a means of
assessing the extent to which access to healthcare is equi-
table. It further involved the generation of a synthesising
argument that has the synthetic construct of candidacy at
its core. For space reasons, we can report here only a brief
illustrative summary.
Critique of utilisation as a measure of access
Much of the evidence on whether access to healthcare in
the UK is equitable has relied on measuring utilisation of
health services. This approach measures the units of
healthcare (consultations, procedures, etc) that people
have actually consumed. The literature suggests that dif-
ferent groups have identifiable patterns of use of services,
but the significance of these is often difficult to interpret.
General practice (GP) consultation rates among socio-
economically disadvantaged people have generally been
found to be higher [28,29] though some recent work has
suggested that social class variables are generally insignif-
icant in explaining health service use [30] Studies that
have attempted to adjust for need, usually on the basis of
estimates of morbidity, have generally suggested that the
apparent excess of GP consultation can be explained by
higher need [31].
Our critique of the literature suggests that utilisation is a
generally unhelpful measure of equity of access. Not only
do the logistical and practical problems of conducting uti-
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lisation studies pose substantial threats to validity and
reliability, these studies are problematic for other reasons.
They rely on a largely untested set of normative (i.e. ideas
about how the world ought to be) and somewhat ques-
tionable assumptions about the "correct" level of utilisa-
tion, and on a difficult-to-measure (or conceputalise)
estimates of "need". They often invoke normative
assumptions about need relative to some apparently priv-
ileged though often ill-defined reference group (such as
"affluent" people), and therefore risk failing to identify
problems in access for that reference group. Misleadingly
reassuring results may be produced that indicate that
"need" and use or receipt are proportionate. We argue that
utilisation, or, more appropriately, receipt of healthcare is
the outcome of many different complex processes, which
all need to be recognised if access is to be properly under-
stood.
Our analysis suggested that a focus instead on candidacy, a
synthetic construct that we generated during the course of
our analysis, would demonstrate the vulnerabilities asso-
ciated with socio-economic disadvantage, emphasise the
highly dynamic, multi-dimensional and contingent char-
acter of access, and allow a more insightful interpretation
of the evidence on receipt of healthcare.
Candidacy
Our synthesising argument around access to healthcare by
socio-economically disadvantaged people is organised
around a set of central concepts and, in particular, the core
synthetic category of "candidacy". Candidacy functions as
a synthetic construct because it is the product of the trans-
formation of the evidence into a new conceptual form. It
is distinct from earlier uses of the term "candidacy",
including its use in the lay epidemiology of heart disease
[32].
We have defined candidacy as follows: candidacy
describes the ways in which people's eligibility for medi-
cal attention and intervention is jointly negotiated
between individuals and health services. Our synthesising
argument runs as follows: candidacy is a dynamic and
contingent process, constantly being defined and rede-
fined through interactions between individuals and pro-
fessionals, including how "cases" are constructed.
Accomplishing access to healthcare requires considerable
work on the part of users, and the amount, difficulty, and
complexity of that work may operate as barriers to receipt
of care. The social patterning of perceptions of health and
health services, and a lack of alignment between the prior-
ities and competencies of disadvantaged people and the
organisation of health services, conspire to create vulner-
abilities. Candidacy is managed in the context of operat-
ing conditions that are influenced by individuals, the
setting and environment in which care takes place, situ-
http://www.biomedcentral.com/1471-2288/6/35
ated activity, the dynamics of face-to-face activity, and
aspects of self (such as gender), the typifications staff use
in categorising people and diseases, availability of eco-
nomic and other resources such as time, local pressures,
and policy imperatives.
Identification of candidacy
How people recognise their symptoms as needing medical
attention or intervention is clearly key to understanding
how they assert a claim to candidacy. Our analysis sug-
gests that people in more deprived circumstances are
likely to manage health and to recognise candidacy as a
series of crises. There is significant evidence of lower use
of preventive services among more deprived groups,
[33,34] as well as evidence of higher use of accident and
emergency facilities, emergency admissions and out-of-
hours use [35,35,37,38]. Among more deprived groups,
there is a tendency to seek help in response to specific
events that are seen as warranting candidacy. "Warning
signs" may be downgraded in importance by socio-eco-
nomically disadvantaged populations because of a lack of
a positive conceptualisation of health, [39,40] the nor-
malisation of symptoms within deprived communities
[41-43], and fear of being "blamed" by health profession-
als [44].
Navigation
Using services requires considerable work on the part of
people. First, people must be aware of the services on
offer, and there has been persistent concern that more
deprived people may lack awareness of some services
[45,46]. Second, using health services requires the mobi-
lisation of a range of practical resources that may be vari-
ably available in the population. A key practical resource
that impacts on the ability to seek care for the socio-eco-
nomically disadvantaged, for example, is transport
[44,47,48]. Other practical resources that may impact on
the ability of disadvantaged groups to negotiate health
services include more rigid patterns of working life [47].
Goddard and Smith [49] summarise evidence suggesting
that those from more deprived social groups face financial
costs of attending health services which, though not suffi-
cient to dissuade them from using services when they are
ill (i.e. in response to a specific "event"), act as a barrier to
attending "optional" services related to health promotion
and health prevention
The permeability of services
Patterns of use of health services reflect issues in the
organisation of services as much as they reflect a tendency
to manage health as a series of crises on the part of disad-
vantaged people. We generated the synthetic construct of
"permeability" to refer to the ease with which people can
use services. Porous services require few qualifications of
candidacy to use them, and may require the mobilisation
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BMC Medical Research Methodology 2006, 6:35
of relatively fewer resources. Such services might include
Accident and Emergency departments. Services that are
less permeable demand qualifications (such as a referral),
and also demand a higher degree of cultural alignment
between themselves and their users, particularly in respect
of the extent to which people feel comfortable with the
organisational values of the service. Such services might
include out-patients clinics in hospitals.
Services that are less permeable tend to have high levels of
default by socio-economically disadvantaged people [50-
53]. Appointments systems, for example, are a threat to
permeability by socio-economically disadvantaged peo-
ple because they require resources and competencies
(including stable addresses, being able to read, and being
able to present in particular places at particular times
[33,50,54] In addition, the extent to which people feel
alienated from the cultural values of health services and
their satisfaction with services have important implica-
tions for which services they choose to use [41,55].
Appearances at health services
Appearing at health services involves people in asserting a
claim to candidacy for medical attention or intervention.
Whatever the nature of the claim, making it clearly
involves work that requires a set of competencies, includ-
ing the ability to formulate and articulate the issue for
which help is being sought, and the ability to present cred-
ibly. More deprived people are at risk in these situations:
they may be less used to or less able to provide coherent
abstracted explanations of need, and may feel intimidated
by their social distance from health professionals. Sword
[56] points out that people with low incomes may feel
alienated by the power relations that often characterise
encounters with professionals. Dixon et al [57] and, in the
US, Cooper and Roter [58] suggest that middle class peo-
ple may be more adept at using their "voice" to demand
better and extensive services: they may be more articulate,
more confident, and more persistent, while people from
lower class backgrounds are less verbally active. Somerset
et al [59] report that in making referral decisions, patients'
social status and their ability to articulate verbally act as
background (and unexpressed) influences that affect the
likelihood of referral.
Adjudications
Once a patient has asserted their candidacy by presenting
to health services, the professional judgements made
about that candidacy strongly influence subsequent access
to attention and interventions. We generated the synthetic
construct of "adjudication" to refer to the judgements and
decisions made by professionals which allow or inhibit
continued progression of candidacy. May et al's [60] anal-
ysis suggests doctors' practices are often exercised through
a repertoire of routine judgements about the possibilities
http://www.biomedcentral.com/1471-2288/6/35
presented by individual patients and the routinely availa-
ble means of solving these. These typifications are, we sug-
gest, strongly influenced by local conditions, including
the operating conditions in which practitioners work and
sensitivity to resource constraints. Candidacy of socially
disadvantaged people appears to be at risk of being judged
to be less eligible, at least for some types of interventions,
although the evidence that this happens is not particularly
strong.
Our analysis suggests that it is likely that professionals'
perceptions of patients who are likely to "do well" as a
result of interventions may disadvantage people in more
deprived circumstances. As Hughes and Griffiths [61]
identify, clinical decisions may rest on often implicit
social criteria about which patients "ought" to receive care
People in disadvantaged groups are more likely to smoke,
to be overweight and to have co-morbidities, and profes-
sional perceptions of the cultural and health capital
required to convert a unit of health provision into a given
unit of health gain may function as barriers to healthcare
[34]. In addition, perceptions of social "deservingness"
may play a role [61,62]. Goddard and Smith [49] summa-
rise evidence suggesting that independent of the severity
of the disease, some GPs are more likely to refer the eco-
nomically active and those with dependants. Clearly,
there is potential for socially disadvantaged people to be
disfavoured in such decisions.
Offers and resistance
Much of the work on utilisation of healthcare explicitly or
implicitly assumes that non-utilisation is a direct reflec-
tion of non-offer. However, this type of normative analy-
sis fails to acknowledge that people may choose to refuse
offers. There is some evidence of patterns of resistance to
offers. Referral implies that a GP has identified particular
features of candidacy and is seeking to match those to a
service that deals with that form of candidacy, but patients
can resist being referred [42,63] and can resist offers of
medication [64,65].
Operating conditions and the local production of
candidacy
A small body of recent research has identified what might
be called local influences on the production of candidacy,
and in our analysis these are hugely important. These are
the contingent and locally specific influences on interac-
tions between practitioners and patients, which may be
emergent over time through repeated encounters. Crucial
to the local production of candidacy is the perceived or
actual availability and suitability of resources to address
that candidacy [60,63].
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BMC Medical Research Methodology 2006, 6:35
Discussion
Demands from health policy-makers and managers for
syntheses of evidence that are useful, rigorous and rele-
vant are fuelling interest in the development of methods
that can allow the integration of diverse types of evidence
[66]. With the diversity of techniques for evidence synthe-
sis now beginning to appear, those using existing, 'new' or
evolving techniques need to produce critical reflexive
accounts of their experiences of using the methods [3].
Our experience of conducting a review of access to health-
care, where there is a large, amorphous and complex body
of literature, and a need to assemble the findings into a
form that is useful in informing policy and that is empiri-
cally and theoretically grounded [67], has led us to pro-
pose a new method – Critical Interpretive Synthesis –
which is sensitised to the kinds of processes involved in
conventional systematic review while drawing on a dis-
tinctively qualitative tradition of inquiry.
Conventional systematic review methodology is well-
suited to aggregative syntheses, where what is required is
a summary of the findings of the literature under a set of
categories which are largely pre-specified, secure, and
well-defined. It has been important in drawing attention
to the weaknesses of informal reviews, including per-
ceived failures in their procedural specification and the
possibility that the (thus) undisciplined reviewer might
be chaotic or negligent in identifying the relevant evi-
dence, or might construct idiosyncratic theories and mar-
shall the evidence in support of these. It has thus revealed
some of the pitfalls of informal literature review. Conven-
tional systematic review methodology has demonstrated
considerable benefits in synthesising certain forms of evi-
dence where the aim is to test theories (in the form of
hypotheses), perhaps especially about "what works".
However, this approach is limited when the aim, con-
fronted with a complex body of evidence, is to generate
theory [15,27].
Current methods for conducting an interpretive synthesis
of the literature, (such as meta-ethnography) are also lim-
ited, in part because application of many interpretive
methods for synthesis has remained confined to studies
reporting qualitative research. Realist synthesis [68],
which does include diverse forms of evidence, is oriented
towards theory evaluation, in particular by focusing on
theories of change. Methods for including qualitative and
quantitative evidence in systematic reviews developed by
the EPPI Centre at the Institute of Education, London,
have involved refinements and extensions of conven-
tional systematic review methodology [6-8], and have
limited their application of interpretive techniques to syn-
thesis of qualitative evidence.
http://www.biomedcentral.com/1471-2288/6/35
More generally, many current approaches fail to be suffi-
ciently critical, in the sense of offering a critique. There is
rarely an attempt to reconceptualise the phenomenon of
interest, to provide a more sweeping critique of the ways
in which the literature in the area have chosen to represent
it, or to question the epistemological and normative
assumptions of the literature. With notable exceptions
such as the recent approach of meta-narrative analysis
[15], critique of papers in current approaches to review
tends to be limited to appraisal of the methodological
specificities of the individual papers.
Conducting an interpretive review of the literature on
access to healthcare by vulnerable groups in the UK there-
fore required methodological innovation that would be
alert to the issues raised by systematic review methodol-
ogy but also move beyond both its limitations and those
of other current interpretive methods. The methods for
review that we developed in this project (Table 2) built on
conventional systematic review methodology in their sen-
sitivity to the need for attentiveness to a range of method-
ological processes. Crucially, in doing so, we drew
explicitly on traditions of qualitative research inquiry, and
in particular on the principles of grounded theory [5].
In addition to its explicit orientation towards theory gen-
eration, perhaps what most distinguishes CIS from con-
ventional systematic review methods is its rejection of a
"stage" approach to review. Processes of question formu-
lation, searching, selection, data extraction, critique and
synthesis are characterised as iterative, interactive,
dynamic and recursive rather than as fixed procedures to
be accomplished in a pre-defined sequence. CIS recog-
nises the need for flexibility in the conduct of review, and
future work would need to assess how far formal methods
of critical appraisal and data extraction will be essential
elements of the method. Our experience suggests that
while attention to scientific quality is required, more gen-
erally the emphasis should be on critique rather than crit-
ical appraisal, and an ongoing critical orientation to the
material examined and to emerging theoretical ideas. For-
mal data extraction may also be an unnecessarily con-
straining and burdensome process.
CIS emphasises the need for theoretical categories to be
generated from the available evidence and for those cate-
gories to be submitted to rigorous scrutiny as the review
progresses. Further, it emphasises a need for constant
reflexivity to inform the emerging theoretical notions, and
guides the sampling of articles. Although CIS demands
attention to flaws in study design, execution and reporting
in our judgements of the quality of individual papers, its
critical approach goes beyond standard approaches. Thus,
in our review, some methodologically weak papers were
important in terms of their theoretical contribution, or in
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Table 2: Key Processes in critical interpretive synthesis

▪ A review question should be formulated at the outset, but should remain open to modification. Precise definitions of many constructs may be
deferred until late in the review and may be a product of the review itself.
▪ Searching, sampling, critique and analysis proceed hand in hand, and should be seen as dynamic and mutually informative processes.
▪ Searching initially should use a broadly defined strategy, including purposive selection of material likely or known to be relevant.
▪ The analysis should be aimed towards the development of a synthesising argument: a critically informed integration of evidence from across the
studies in the review. The synthesising argument takes the form of a coherent theoretical framework comprising a network of constructs and the
relationships between them. The synthesising argument links synthetic constructs (new constructs generated through synthesis) and existing
constructs in the literature.
▪ There is a need for constant reflexivity to inform the emerging theoretical notions, as these guide the other processes.
▪ Ongoing selection of potentially relevant literature should informed by the emerging theoretical framework. Literatures not directly or obviously
relevant to the question under review may be accessed as part of this process.
▪ CIS encourages an ongoing critical orientation to the material to be included in the review. Some limited formal appraisal of methodological
quality of individual papers is likely to be appropriate. Generally the aim will be to maximise relevance and theoretical contribution of the included
papers.
▪ Formal data extraction procedures may be helpful, particularly at the outset of the review, but are unlikely to be an essential feature of the
approach.
▪ CIS does not offer aim to offer a series of pre-specified procedures for the conduct of review. It explicitly acknowledges the "authorial voice"; that
some aspects of its production of the account of the evidence will not be visible or auditable; and that its account may not be strictly reproducible.
Its aim is to offer a theoretically sound and useful account that is demonstrably grounded in the evidence.
▪ CIS demands constant reflexivity on the part of authors of reviews. Authors are charged with making conscientious and thorough searches, with
making fair and appropriate selections of materials, with seeking disconfirming evidence and other challenges to the emergent theory, and with
ensuring that the theory they generate is, while critically informed, plausible given the available evidence.

terms of demonstrating the breadth of evidence consid-
ered in the construction of particular categories, or in
terms of providing a more comprehensive summary of the
evidence, while a single strong paper might be pivotal in
the development of the synthesis. Hughes and Griffiths'
paper on micro-rationing of healthcare [61], for example,
was a key paper in helping to generate the construct of
candidacy that later came to unify the themes of our anal-
ysis. The critical interpretation in our analysis focused on
how a synthesising argument could be fashioned from the
available evidence, given the quality of the evidence and
the kinds of critiques that could be offered of the theory
and assumptions that lay behind particular approaches.
In treating the literature as an object of scrutiny in its own
right, CIS problematises the literature in ways that are
quite distinctive from most current approaches to litera-
ture reviewing.
Access to healthcare
The CIS approaches we adopted deferred final definition
of the phenomenon of access and the appropriate ways of
conceptualising it until our analysis was complete. Our
critique of the current literature focused on the inadequa-
cies of studies of utilisation as a guide to explaining ineq-
uities in health care. The conceptual model of access that
we developed emphasises candidacy as the core organis-
ing construct, and recasts access as highly dynamic and
contingent, and subject to constant negotiation.
appropriate objects of medical attention and intervention.
Candidacy describes how people's eligibility for health-
care is determined between themselves and health serv-
ices. Candidacy is a continually negotiated property of
individuals, subject to multiple influences arising both
from people and their social contexts and from macro-
level influences on allocation of resources and configura-
tion of services. "Access" represents a dynamic interplay
between these simultaneous, iterative and mutually rein-
forcing processes. By attending to how vulnerabilities
arise in relation to candidacy, the phenomenon of access
can be much better understood, and more appropriate
recommendations made for policy, practice and future
research. Although our review focused on the UK, we sug-
gest that the construct of candidacy is transferable, and
has useful explanatory value in other contexts.
In addition to the core construct of candidacy, our analy-
sis required the production of a number of other linked
synthetic constructs – constructs generated through an
attempt to summarise and integrate diverse concepts and
data – including "adjudications" and "offers". It was also
possible to link existing "second order" constructs, for
example relating to help-seeking as the identification of
candidacy by patients, into the synthesising argument,
and making these work as synthesising constructs. We feel
that this approach allows maximum benefit to be gained
from previous analyses as well as the new synthesis.

In this conceptual model of access to healthcare, health Reflections on the method

services are continually constituting and seeking to define Clearly, questions can be raised about the validity and
the appropriate objects of medical attention and interven- credibility of the CIS analysis we have presented here.
tion, while at the same time people are engaged in consti- Conventional systematic review methodology sets great
tuting and defining what they understand to be the store by the reproducibility of its protocols and findings.

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It would certainly have been possible to produce an
account of the evidence that was more reproducible. For
example, we could have used the evidence to produce a
thematic summary that stuck largely to the terms and con-
cepts used in the evidence itself. However, we felt it
important that we produced an interpretation of the evi-
dence that could produce new insights and fresh ways of
understanding the phenomenon of access, and that the
"critical voice" of our interpretation was maintained
throughout the analysis. Simply to have produced a the-
matic summary of what the literature was saying would
have run the risk of accepting that the accounts offered in
the evidence-base were the only valid way of understand-
ing the phenomenon of access to healthcare by vulnerable
groups. We therefore make no claim to reproducibility,
but wish to address some possible concerns. First, it could
be argued that a different team using the same set of
papers would have produced a different theoretical
model. However, the same would be true for qualitative
researchers working with primary qualitative data, who
accept that other possible interpretations might be given
to, say, the same set of transcripts. Clearly, the production
of a synthesizing argument, as an interpretive process,
produces one privileged reading of the evidence, and, as
the product of an authorial voice, it cannot be defended as
an inherently reproducible process or product. We would
suggest, however, that our analysis can be defended on the
grounds that it is demonstrably grounded in the evidence;
that it is plausible; that it offers insights that are consistent
with the available evidence; and that it can generate testa-
ble hypotheses and empirically valuable questions for
future research.
Second, subjecting a question to continual review and
refinement, as we did, may make it more difficult for
those conducting critical interpretive reviews to demon-
strate, as required by conventional systematic review
methodology, the "transparency", comprehensiveness,
and reproducibility of search strategies. This dilemma
between the "answerable" question and the "meaningful"
question has received little attention, but it underpins key
tensions between the two ends of the academic/pragmatic
systematic review spectrum. On balance, faced with a
large and amorphous body of evidence in an area such as
access to healthcare, and given the aims of an interpretive
synthesis, we feel that our decision not to limit the focus
of the review at the outset, and our subsequent sampling
strategies, were well justified. Our decision not to commit
to a particular view of what access might be and how it
should be assessed at the outset of the project was critical
to our subsequent development of a more satisfactory
understanding of access.
Third, it could be argued that we have synthesized too
small a sample of the available papers, or that the proc-
http://www.biomedcentral.com/1471-2288/6/35
esses used to select the papers are not transparent. We rec-
ognize that we have analyzed and synthesized only a
fraction of all relevant papers in the area of access to
healthcare by vulnerable groups. However, a common
strategy in conventional systematic review is to limit the
study types to be included; this strategy also might result
in only a proportion of the potentially relevant literature
being synthesised. While we have described our methods
for sampling as purposive, it is possible that another team
using the same approach could have come up with a dif-
ferent sample, because, particularly in the later stages of
our review, our sampling was highly intuitive and guided
by the emerging theory.
The final version of the conceptual model of access to
healthcare that we eventually developed did not emerge
until quite late in the review process, and much of the
later sampling was directed at testing and purposively
challenging the theory as we began to develop it. Again,
such forms of searching and sampling do not lend them-
selves easily to reproducibility or indeed auditability. Test-
ing whether the interpretations change in response to
different findings will be an important focus for future
research, which will also need to evaluate whether appar-
ently disconfirming evidence is the result of methodolog-
ical flaws or poses a genuine challenge to theory.
Conclusion
Conducting interpretive reviews in challenging areas
where there is a large body of diverse evidence demands
an approach that can draw on the strengths of conven-
tional systematic review methodology and on the recent
advances in methods for interpretive synthesis. We have
termed the approach we developed to this review "critical
interpretive synthesis". We believe that this methodology
offers the potential for insight, vividness, illumination,
and reconceptualisation of research questions, particu-
larly in challenging areas such as access to healthcare, and
look forward to further evaluations of its application.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
MDW designed the project, led and supervised its execu-
tion, and drafted the manuscript. EA, AA, JH, RH, SK, RO,
LS, RR and AJS participated in the design of the study. All
authors engaged in searching, screening, sampling, data
extraction, and critical appraisal/critique activities, and
contributed to the thematic analysis. DC and SA managed
the searching, maintained the databases and coded mate-
rial using N6 software. All authors contributed to the draft
of the manuscript.
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BMC Medical Research Methodology 2006, 6:35
Acknowledgements
This project was funded by the NHS Service Delivery and Organisation
(SDO) Research Programme.
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